Rail safety investigations & reports

Safeworking irregularity involving train 9261 Sellheim Station, Mount Isa Line, Queensland, on 28 July 2020

Investigation number:
RO-2020-014
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

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What happened

On 28 July 2020, the driver of Aurizon train 9261 told the Queensland Rail (QR) network control officer (NCO) the train was approaching its limit of authority at Sellheim Station, where it would stop to cross road-rail vehicle ZH42 travelling in the opposite direction. As 9261 entered the station, the driver triggered a counter in the locomotive cab to measure the distance travelled. The driver then stopped 9261 next to a trackside information sign that displayed the text ‘Stop at this point unless holding DTC (direct traffic control) Authority to Mingela’. The driver determined the train to be complete and in-clear of the track section to the rear and supplied a release code to the NCO.

The NCO confirmed the location of train 9261 and issued an authority for ZH42 to continue onto the track section that 9261 had reportedly vacated. Shortly after, the driver of ZH42 advised the NCO that the rear wagons of train 9621 were not in-clear and estimated that two and a half wagon lengths were occupying the track section ahead.

What the ATSB found

QR had installed the information signs at Sellheim Station in 2015 as a measure to address noise complaints from members of the public living near the station. The signs were located 940 m past the block limit boards (BLBs), whereas the maximum train length permitted was 1,009 m, and drivers were not advised of the distance from the signs to the BLBs. When installing the information signs, QR personnel did not complete a formal infrastructure change approval process or risk assessment to consider the potential operational implications of the signs.

The driver of 9261 used the information sign location as a reference point for stopping rather than cross-checking the in-cab counter readout against the train comparison length. Subsequently, the driver erroneously provided the NCO with a release code for the Charters Towers to Sellheim section block.

QR’s DTC system provided limited functionality for an NCO to verify the physical availability of a released section block prior to issuing an authority to the opposing rail traffic. This placed increased reliance on a second (opposing) train crew checking the other train to detect the occupied section block in sufficient time to avoid a collision.

What has been done as a result

Queensland Rail (QR) undertook a risk assessment of the information signs at Sellheim Station and subsequently moved the signs to the 110.109 km point, approximately 134 m east of the first location. The revised location provided about 1,060 m between BLBs and the associated information signs. QR also started a program of works to find locations on the Mount Isa Line and other lines where inconsistencies existed between the trackside infrastructure and the information contained in route maps, signalling arrangement diagrams and the DTC software.

Safety message

Given the limitations of DTC, rail traffic crew of the first traffic to stop at a directional travel station to undertake a cross or pass with other rail traffic must ensure their traffic is complete and in-clear before releasing the section block to the NCO.

In addition, rail infrastructure managers should carefully consider the potential for information signs to be misinterpreted by rail traffic crew, particularly if such signs contain the word ‘Stop’.  This occurrence also highlights the importance of rail infrastructure managers conducting appropriate change management and risk assessment processes when introducing changes to their infrastructure.

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[Download  PDF: 1018KB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety actions

Glossary

Sources and submissions

About the ATSB

General details
Date: 28 July 2020   Investigation status: Completed  
Time: 0930 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Sellheim Station, 18 km east of Charters Towers, Mount Isa Line   Investigation phase: Final report: Dissemination  
State: Queensland    
Release date: 25 August 2021   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Train 1 details

Train 1 details
Line operator Queensland Rail  
Train operator Aurizon  
Train registration 9261  
Type of operation Bulk  
Sector Freight  
Damage to train Nil  

Train 2 details

Train 2 details
Line operator Queensland Rail  
Train operator Queensland Rail  
Train registration ZH42  
Type of operation Track Maintenance  
Sector Other  
Damage to train Nil  
Last update 25 August 2021